Francesco Dimitri Petridis

Acute kidney injury following transcatheter aortic valve implantation: incidence, predictors and clinical outcome

BACKGROUND Limited data exist on renal complications of transcatheter aortic valve implantation (TAVI) within a comprehensive program using different valves with transfemoral, transapical, and trans-subclavian approach. METHODS Prospective single-center registry of 102 consecutive patients undergoing TAVI using both approved bioprostheses and different access routes. The main objective was to assess the incidence, predictors and the clinical impact of acute kidney injury (AKI). AKI was defined according to the valve academic research consortium (VARC) indications. RESULTS Mean age was 83.7 ± 5.3 years, logistic EuroSCORE 22.6 ± 12.4%, and STS score 8.2 ± 4.1%. Chronic kidney disease at baseline was present in 87.3%. Periprocedural AKI developed in 42 patients (41.7%): 32.4% stage 1, 4.9% stage 2 and 3.9% stage 3. The incidence of AKI was 66.7% in transapical, 30.3% in transfemoral, and 50% in trans-subclavian procedures. The only independent predictor of AKI was transapical access, with a hazard ratio (HR) between 4.57 and 5.18 based on the model used. Cumulative 1-year survival was 88.2%. At Cox regression analysis, the only independent predictor of 30-day mortality was diabetes mellitus (HR 7.05, 95% CI 1.07-46.32; p=0.042), whilst the independent predictors of 1-year death were baseline glomerular filtration rate<30 mL/min (HR 5.74, 95% CI 1.42-23.26; p=0.014) and post-procedural AKI 3 (HR 8.59, 95% CI 1.61-45.86, p=0.012). CONCLUSIONS TAVI is associated with a high incidence of AKI. Although in the majority of the cases AKI is of mild entity and reversible, AKI 3 holds a strong negative impact on 1-year survival. The incidence of AKI is higher with transapical access.

Integrative miRNA and whole-genome analyses of epicardial adipose tissue in patients with coronary atherosclerosis

BACKGROUND Epicardial adipose tissue (EAT) is an atypical fat depot surrounding the heart with a putative role in the development of atherosclerosis. METHODS AND RESULTS We profiled genes and miRNAs in perivascular EAT and subcutaneous adipose tissue (SAT) of metabolically healthy patients without coronary artery disease (CAD) vs. metabolic patients with CAD. Compared with SAT, a specific tuning of miRNAs and genes points to EAT as a tissue characterized by a metabolically active and pro-inflammatory profile. Then, we depicted both miRNA and gene signatures of EAT in CAD, featuring a down-regulation of genes involved in lipid metabolism, mitochondrial function, nuclear receptor transcriptional activity, and an up-regulation of those involved in antigen presentation, chemokine signalling, and inflammation. Finally, we identified miR-103-3p as candidate modulator of CCL13 in EAT, and a potential biomarker role for the chemokine CCL13 in CAD. CONCLUSION EAT in CAD is characterized by changes in the regulation of metabolism and inflammation with miR-103-3p/CCL13 pair as novel putative actors in EAT function and CAD.

Reoperative surgery on the thoracic aorta.

OBJECTIVE The objective of our study was to report our hospital and long-term results after reinterventions on the thoracic aorta. METHODS Between 1986 and 2011, 224 reoperations on the proximal thoracic aorta after previous aortic surgery were performed in our institution. The number of reinterventions quadrupled during the course of the study period. Mean patient age was 58.1 years, and 174 patients (77.7%) were male. An urgent/emergency operation was performed in 39 patients (17.4%). Indications for surgery included degenerative and chronic postdissection aneurysm (n = 166), false aneurysm (n = 31), active prosthetic infection (n = 16), acute dissection (n = 10), and other (n = 1). Surgical procedures involved the aortic root in 40.6% of patients, the ascending aorta in 9.4%, the aortic arch in 24.6%, and the entire proximal thoracic aorta in 25.4%. RESULTS Hospital mortality was 12.1%. On multivariate analysis, cardiopulmonary bypass time (odds ratio, 1.1023/minute; P < .001), and urgent/emergency status (odds ratio, 5.6; P < .001) emerged as independent predictors of hospital mortality. The follow-up was 98.7% complete. Estimated 1-, 5-, and 10-year survival rates were 84.4%, 72.5%, and 48.5%, respectively. Eighteen reinterventions were performed during follow-up-16 because of the progression of aortic disease at the proximal aorta (n = 2) and downstream aorta (n = 14). Freedom from reoperation at 1, 5, and 10 years was 95.6%, 90.2%, and 81.5%, respectively. CONCLUSIONS Reoperative aortic surgery was associated with satisfactory short- and long-term results, especially if carried out on an elective basis. The extent of the aortic replacement did not impact survival and was associated with a reduced need for reintervention. The progressive nature of aortic disease and the favorable results of elective primary aortic interventions suggest favoring aggressive aortic resections at initial surgery.

Impact of Different Cannulation Strategies on In-Hospital Outcomes of Aortic Arch Surgery: A Propensity-Score Analysis

BACKGROUND The impact of different cannulation strategies on outcomes of aortic arch surgery remains controversial. This retrospective study sought to evaluate central cannulation (ascending aorta, right axillary, and innominate artery) compared with femoral artery cannulation for aortic arch surgery, and to identify among preoperative and intraoperative variables the independent predictors of death and permanent neurologic dysfunction (PND) in aortic arch surgery. METHODS All patients were operated through a median sternotomy using antegrade selective cerebral perfusion with moderate hypothermia as a method of brain protection. Treatment bias was addressed by use of propensity-score matching and multivariate regression analysis. Logistic regression models were used to identify the independent predictors of hospital mortality and PND. RESULTS Of the 473 patients undergoing aortic arch surgery, 273 (57.7%) underwent femoral cannulation (FC), and 200 (42.3%) underwent central cannulation (CC). The CC and FC cannulation were associated with similar risk of in-hospital death (absolute risk reduction [ARR]: 0.7%; p = 0.880) and PND (ARR:-2.6%, p = 0.361) in the overall cohort and after adjusting for propensity-based matching (ARR for hospital mortality: 2.2%, p = 0.589; ARR for PND: 3.4%, p = 0.271). Female gender (odds ratio [OR]:2.1, p = 0.030), type A acute dissection or intramural hematoma (OR: 2.2; p = 0.041), and CPB time (OR: 1.010/minute, p = 0.015) were independent predictors of in-hospital death. Female gender (OR: 2.4; p = 0.033), type A acute dissection or intramural hematoma (OR: 4.2; p = 0.005), and diabetes (OR: 6.6, p = 0.007) were independent predictors of PND. CONCLUSIONS During aortic arch surgery, CC and FC are associated with a similar risk of postoperative death and PND. Type A acute aortic dissection and cardiopulmonary bypass time remain strong risk factors for mortality and PND.

Conventional versus frozen elephant trunk surgery for extensive disease of the thoracic aorta

Objective To compare early and mid-term outcomes after repair of extensive aneurysm of the thoracic aorta using the conventional elephant trunk or frozen elephant trunk (FET) procedures. Methods Fifty-seven patients with extensive thoracic aneurysmal disease were treated using elephant trunk (n = 36) or FET (n = 21) procedures. Patients with aortic dissection, descending thoracic aorta (DTA) diameter less than 40 mm, and thoracoabdominal aneurysms were excluded from the analysis, as were those who did not undergo antegrade selective cerebral perfusion during circulatory arrest. Short-term and mid-term outcomes were compared according to elephant trunk/FET surgical management. Results Preoperative and intraoperative variables were similar in the two groups, except for a higher incidence of female sex, coronary artery disease and associated procedures in elephant trunk patients. Hospital mortality (elephant trunk: 13.9% versus FET: 4.8%; P = 0.2), permanent neurologic dysfunction (elephant trunk: 5.7% versus FET: 9.5%; P = 0.4) and paraplegia (elephant trunk: 2.9% versus FET: 4.8%; P = 0.6) rates were similar in the two groups. Follow-up was 100% complete. In the elephant trunk group, 68.4% of patients did not undergo a second-stage procedure during follow-up for a variety of reasons. Of these patients, the DTA diameter was greater than 51 mm in 72.2% and two (6.7%) died due to aortic rupture while awaiting stage-two intervention. Endovascular second-stage procedures were successfully performed in all FET patients with residual DTA aneurysmal disease (n = 3), whereas nine of 11 elephant trunk patients who returned for second-stage procedures required conventional surgical replacement through a lateral thoracotomy. Kaplan–Meier estimate of 4-year survival was 75.8 ± 7.6 and 72.8 ± 10.6 in elephant trunk and FET patients, respectively (log-rank P = 0.8). Conclusion In patients with extensive aneurysmal disease of thoracic aorta, elephant trunk and FET procedures seem to be associated with similar satisfactory early and mid-term outcomes. The FET approach leads to single-stage treatment of all aortic disease in most patients, and facilitates endovascular second-stage treatment in patients with residual DTA disease. The elephant trunk staged-approach appears to leave a considerable percentage of patients at risk for adverse aortic events.

Awake transapical aortic valve implantation

Transapical aortic valve implantation is being employed as a less invasive alternative to open heart surgery in high-risk patients with severe aortic stenosis. Here we report the case of an awake transapical aortic valve implantation in a patient with severe chronic obstructive pulmonary disease.

Reinterventi sulla radice aortica: risultati a breve e lungo termine in 111 pazienti

BACKGROUND The aim of this study was to report results of aortic root reoperations and to identify predictors of in-hospital and long-term mortality. METHODS Between 1986 and 2011, 111 consecutive patients (mean age 55.4 years, 85 male [76.6%]) were reoperated on the aortic root after previous aortic surgery at our institution. An urgent/emergent operation was performed in 24 patients (21.6%). Indications for reoperation were degenerative aneurysm (n = 56), chronic post-dissection aneurysm (n = 27), active prosthetic infection (n = 14), false aneurysm (n = 10) and acute dissection (n = 4). Surgical procedures were limited to the aortic root in 68 patients (61.3%), and involved the entire proximal thoracic aorta in 43 patients (38.7%). RESULTS In-hospital mortality was 12.6%, being 6.9% and 33.3% in elective and urgent cases, respectively (p=0.002). On multivariate analysis, cardiopulmonary bypass time (odds ratio 1.029/min; p=0.011) and urgent/emergent status (odds ratio 8.486; p=0.044) were independent predictors of in-hospital mortality. Follow-up was 99.1% complete. Estimated 1-, 5-, and 10-year survival rates were 82.5%, 71.9% and 50.6%, respectively. Six redo procedures were performed during follow-up. Freedom from reoperation at 1, 5, and 10 years was 100%, 91.7% and 86.1%, respectively. On Cox regression analysis, chronic aortic dissection (hazard ratio 21.2; p=0.009) was an independent predictor of reintervention at follow-up. CONCLUSIONS Reoperation on the aortic root can be performed with acceptable mortality and good mid- and long-term outcomes, in particular when carried out on an elective basis. Cardiopulmonary bypass time and urgent/emergent status remain the most important risk factors for reduced survival in aortic surgery.BACKGROUND: The aim of this study was to report results of aortic root reoperations and to identify predictors of in-hospital and long-term mortality. METHODS: Between 1986 and 2011, 111 consecutive patients (mean age 55.4 years, 85 male [76.6%]) were reoperated on the aortic root after previous aortic surgery at our institution. An urgent/emergent operation was performed in 24 patients (21.6%). Indications for reoperation were degenerative aneurysm (n = 56), chronic post-dissection aneurysm (n = 27), active prosthetic infection (n = 14), false aneurysm (n = 10) and acute dissection (n = 4). Surgical procedures were limited to the aortic root in 68 patients (61.3%), and involved the entire proximal thoracic aorta in 43 patients (38.7%). RESULTS: In-hospital mortality was 12.6%, being 6.9% and 33.3% in elective and urgent cases, respectively (p=0.002). On multivariate analysis, cardiopulmonary bypass time (odds ratio 1.029/min; p=0.011) and urgent/emergent status (odds ratio 8.486; p=0.044) were independent predictors of in-hospital mortality. Follow-up was 99.1% complete. Estimated 1-, 5-, and 10-year survival rates were 82.5%, 71.9% and 50.6%, respectively. Six redo procedures were performed during follow-up. Freedom from reoperation at 1, 5, and 10 years was 100%, 91.7% and 86.1%, respectively. On Cox regression analysis, chronic aortic dissection (hazard ratio 21.2; p=0.009) was an independent predictor of reintervention at follow-up. CONCLUSIONS: Reoperation on the aortic root can be performed with acceptable mortality and good mid- and long-term outcomes, in particular when carried out on an elective basis. Cardiopulmonary bypass time and urgent/emergent status remain the most important risk factors for reduced survival in aortic surgery.

Angiographic aspect of longstanding Starr-Edwards valve for type C Ebstein anomaly

A 66-year-old man was admitted with dyspnea during normal activities (New York Heart Association class III). At 12-years-old, he had received a classic BlalockTaussig shunt for type C Ebstein anomaly according to Carpentier’s classification. At 35-years old, he underwent tricuspid valve replacement with a 30-mm StarrEdwards caged ball prosthesis (model unknown) for severe tricuspid valve regurgitation associated with surgical ablation for Wolf-Parkinson-White syndrome and placement of a heterologous pericardial patch in the right ventricular outflow tract. At this admission, he was on warfarin therapy (international normalized ratio 2.79). Transthoracic echocardiography demonstrated severe biatrial dilation (left atrial volume index 48mL m , right atrial volume index 52mL m ), reduced biventricular systolic function (left ventricular diastolic volume index 66mL m , left ventricular ejection fraction 30%, S-wave velocity 3 cm s ), and mild mitral and aortic valve regurgitation with preserved function of the tricuspid valve prosthesis (mean gradient 4mm Hg and no regurgitation). Angiography revealed no coronary artery disease and a well-functioning tricuspid valve prosthesis (Figure 1, Video 1). Computed tomography and pulmonary function tests showed that severe mixed respiratory impairment was the primary origin of the patient’s clinical status. Spirometry tests showed a moderate restrictive deficit. This is a rare report of a longstanding well-functioning StarrEdwards valve in the tricuspid position.

Neonatal aortic coarctation: a spectrum of anatomic lesions repaired trough left thoracotomy in 22 years experience

Methods One hundred and thirty-four patients underwent CoA repair from January 1990 to December 2012 (mean FU 115.6±82.9 months). Mean age was 11.5±7.6 days (range 0-30 days). Mean weight was 3.0±0.7kg, 26.1% under 2.5kg of weight. 88 patients (65.7%) presented isolated CoA,36 (26.9%) associated VSD, 10 (7.5%) associated complex cardiac defects. All patients were treated through left thoracotomy, 79.9% with end to end extended anastomosis, 7.4% with prosthetic and 12.7% with subclavian patch. Concomitant pulmonary artery banding was performed in 28 patients (21.1%). During follow up all patients underwent thoracic aortic MR and cardiological evaluation. Cerebral MR angiography was performed to avoid the risk of the association between neonatal CoA repair and IAs development.

The repaired tetralogy of Fallot become adult: what should we expect

Methods 82 patients with repaired tetralogy of Fallot were collected from the database of our pediatric and congenital adult cardiology and cardiac surgery unit. Only patients older than 16 years of age at the time of the study were selected. All patients underwent complete surgical repair during childhood at a mean age of1.6±1.3 years. Forty-nine patients (71.9%) were treated with transannular patch, 17(23.2%) infundibular patch, 3(3.65%) endoventricular repair and 1(1.2%) with conduit between the right ventricle(RV) and the pulmonary artery(PA); 17/82(20.7%) of all patients required palliative BT shunt at birth before repair. Mean age at follow up was 23.7± 6.7 years. Follow-up schedule comprised clinical evaluation along with echocardiographic and cardiac-MR, quality of life and VO2 consumption assessment.